INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 12, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Washington House was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.5 (c) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(c) No more than four residents may share a bedroom.
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Observations
Based on a physical plant inspection conducted on May 12, 2016 at approximately 11:00 am and again at 3:00 pm, it was observed that the facility had more than four residents in two 2nd floor bedrooms.
Bedroom #1: There were 3 single beds and a bunk bed. Each bed was assigned a client at the time of the inspection.
Bedroom #5: There were 5 single beds. Each bed was assigned a client at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of July 1, 2016 one bed was removed from room #1 and was placed in room #6 totaling four beds for the two rooms.
As of 8/5/16 Room#5 on single bed was removed leaving only four beds. The handicap accessible bedroom was reestablished which consist of one bed.
Program Director will do a monthly bed count to ensure that all rooms remain in compliance. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
The facility failed to inform their clients of their rights in ten out of ten client records reviewed during the annual licensing inspection conducted on May 12, 2016.
All clients receiving drug and alcohol treatment are required to be informed of their rights. A client rights form is presented to all clients for signature; however, the form that the clients are signing does not contain all the required items. The following items were not listed on the form: The client ' s right to appeal a decision limiting access to their records to the director, their right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records and their right to submit rebuttal data or memoranda to their own records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By May 30, 2016 Program Director met with intake Specilist and instructed her to update all intake package to include Gaudenzia "Client Bill of Rights" which include #3; The right to examine one's own record within the guideline approved by the agency in accordance with Federal regulations 42CFR, and rebut any information in their records by insertung a counter statement of clarification or correction". By May 30, 2016 a inservice was conducted by Program Director reviewing Gaudenzia's "Client Bill Of Rights" to ensure all staff are familiar with the correct form and understands members' right.Program Director reviewed Intake Specialist Master package to ensure correct Client Bill Of Right is being signed during intake.
During weekly chart review for the next three months Clinical Supervisor will examine chart content to ensure all correct forms are being used.
During community meeting, held on 5/30/16 Client Bill of Rights were reviewed to ensure their understanding of their rights. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, #1, 3, 4, 6 and 8, the facility failed to document on the treatment and rehabilitation plan the frequency of services.
#1 - The comprehensive treatment plan, dated 4/14/2016, was missing the frequency.
#3 - The comprehensive treatment plan, dated 04/01/2016, was missing the frequency.
#4 - The comprehensive treatment plan, dated 04/11/2015, was missing the frequency.
#6 - The comprehensive treatment plan, dated 10/29/2016, was missing the frequency.
#8- The comprehensive treatment plan, dated 2/11/2016, was missing the frequency.
The findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
As of May 20, 2016 all Clinicians were trained by Clinical Supervisor on recording the type and frequency of members' treatment plan services. Members' charts are reviewed weekly by Clinical Supervisor to ensure recording is occurring according to required standard. Clinical supervsior reports to Program Director weekly on the status and compliancy of all members charts for the next three months.
By May 20,2016 all counselors made corrections to member's charts reflecting the frequency of members' treatment plan services. Clinical Supervisor reviewed all charts to ensure corrections were made. |